Triggering Agents Research Articles

Evaluation of 119 Anaesthetics Received After Investigation for Susceptibility to Malignant Hyperthermia

A questionnaire was sent to the first 371 patients investigated for MH susceptibility at the Danish MH Register, in order to assess sequelae from the muscle biopsy and possible subsequent anaesthetic complications. The purpose was to evaluate both the safety of anaesthetizing MH-susceptible (MHS) patients without the use of trigger agents, and the safety of giving trigger agents to non-susceptible (MHN) patients. Eighty-eight per cent of patients alive replied to the questionnaire. Of these, 22% complained about discomfort at the site of the biopsy, 2% had experienced problems when needing a subsequent anaesthetic, and 0.9% had had trouble when applying for life or accident insurance. The median observation period for all patients following the muscle biopsy was 5.5 years (range 27 months-11 years). During this period, 36 MHS patients had been anaesthetized 52 times (28 general and 23 regional anaesthetics, data missing in one case) without any MH-related complications. None of the patients had received prophylactic dantrolene. Three MHE patients had received non-trigger anaesthetic agents on three occasions without development of MH. Thirty-five MHN patients had been anaesthetized 64 times, and 13 of these MHN patients had received trigger agents 26 times without any signs of MH. An estimate of the probability of clinical MH developing in MHN patients subsequently anaesthetized with trigger agents was found to be 0-24.7% (95% confidence limits), whereas the probability of clinical MH developing in MHS patients anaesthetized with non-trigger agents was 0-9.7% (95% confidence limits).

Anaesthesia for Charcot-Marie-Tooth disease: a review of 86 cases.

Operative charts were reviewed in 86 patients with Charcot-Marie-Tooth disease, a condition characterized by chronic muscular denervation. A total of 161 surgical procedures was performed. Major complications were few, and only one operative death occurred, unrelated to anaesthesia. Succinylcholine and malignant hyperthermia triggering agents were used in 41 (48%) and 77 (90%) patients, respectively, without untoward effects. Contrary to previous reports, this survey supports the safe use of succinylcholine and MH triggering agents in this disease.

Intestinal gluten sensitivity: snapshots of an unusual autoimmune-like disease

Gluten-sensitive disease is activated in genetically susceptible individuals by the ingestion of wheat protein (gluten). Breakdown in normal tolerogenic processes to dietary gluten is likely to play a primary pathogenic role. The disease is characterized by several autoimmune-type features and provides a model for studying autoimmune processes. A recent meeting emphasized the need for a clearer picture of the molecular interactions between disease triggering agents, molecules of the immune system and other products of disease susceptibility genes.

Effect of the c-kit Ligand on Mediator Release by Human Lung Mast Cells.

IgE-independent mediator release or modulation of mediator release by cytokines has not been described for human lung mast cells (MC) so far. We recently showed that among a large number of cytokines examined the c-kit ligand (KL) is a unique cytokine capable of modulating histamine and leukotriene release in human lung mast cells. KL increases the IgE-dependent mediator release 2- to 3-fold without inducing substantial mediator release over the control by itself in freshly isolated cells. By contrast, this study shows that KL becomes a potent triggering agent per se in MC cultured for a few days without addition of KL or feeder cells. Furthermore, the IgE-dependent response is strongly enhanced after culture. The present study indicates that human and rodent MC differ strongly in their functional repsonsiveness towards cytokines, and that KL may be an important regulator of mast cell-associated disease, such as asthma.

Aphthous stomatitis (canker sores): A consequence of high oral submucosal viscosity (the role of extracellular matrix and the possible role of lectins)

Recurrent aphthous stomatitis (RAS) or canker sores occur in 20–60% of all persons. The lesion occurs because of increased viscosity of oral submucosal extracellular matrix (ECM). The lesions begin in the second decade and peak in the third decade. Sex hormones are an important influence on fibroblasts, especially in the early phase of exposure. Sex hormones are known to concentrate, to a degree, in the bucal mucosa in animals. Lesions of RAS localize clinically and experimentally at sites of trauma. In the skin, edema is known to trigger early cellular inflammation. Increased viscosity of ECM heightens the response. The histopathology of the ulcerated lesions is similar to that which occurs under sites of acute inflammation in the skin. Systemic corticosteroids completely supress the lesions. Caustics, such as silver nitrate and phenol, stop the growth and pain of lesions. Irritants are known to break ECM viscosity. The oral mucosa exerts some control on underlying ECM. Substances such as lectins influencing the mucosa could influence ECM. Soluble substances in food or organisms could also penetrate to influence ECM. A number of different foods have been incriminated as trigger agents in individual cases. This includes gluten in patients with gluten sensitive enteropathy. Gluten is know to alter the mucosa of the small intestine in persons with celiac disease.

Maligne Hyperthermie heute

Besides offering a concise recapitulation of known facts, experiences and related viewpoints concerning malignant hyperthermia (MH), the present article offers a review of the most relevant new aspects in this field. Special emphasis is on genetics and pathogenesis of MH. The contents of the review are as follows: History; Definition of MH; Epidemiological aspects; Inheritance; Molecular genetics; Pathogenesis; Triggering agents; Awake Triggering; Sympathetic nervous system; Serotoninergic system; Involvement of other organs and cell systems; Clinical symptoms and diagnosis; MH and myopathies; Associated disorders; Treatment; Prophylaxis; Identification of susceptibility; MH testing centres in the FRG; Hot-line for MH emergencies

Frühdiagnose der malignen Hyperthermie - zum Stellenwert des endexspiratorischen CO2-Monitorings

The authors report on the course of a fulminant malignant hyperthermia (MH) associated with laminectomy in a 29-year-old man who had been healthy up to that time. Succinylcholine and isoflurane were considered to be the causative triggering agents. Progression could be prevented due to an early suspicion raised by end-expiratory CO2 measurement: treatment was instituted immediately (Dantrolene 2mg/kg body weight, oxygen hyperventilation, external cooling, etc.) Serum creatine kinase increased up to almost 50,000 U/l associated with massive myoglobinuria. Residue-free restitution was achieved within a few days. Decisive for an early detection of MH is the routine performance of end-expiratory CO2 measurement which is definitely superior to temperature control and significantly reduces the time that elapses before treatment is initiated.

Evaluation of 119 anaesthetics received after investigation for susceptibility to malignant hyperthermia

A questionnaire was sent to the first 371 patients investigated for MH susceptibility at the Danish MH Register, in order to assess sequelae from the muscle biopsy and possible subsequent anaesthetic complications. The purpose was to evaluate both the safety of anaesthetizing MH-susceptible (MHS) patients without the use of trigger agents, and the safety of giving trigger agents to non-susceptible (MHN) patients. Eighty-eight per cent of patients alive replied to the questionnaire. Of these, 22% complained about discomfort at the site of the biopsy, 2% had experienced problems when needing a subsequent anaesthetic, and 0.9% had had trouble when applying for life or accident insurance. The median observation period for all patients following the muscle biopsy was 5.5 years (range 27 months-11 years). During this period, 36 MHS patients had been anaesthetized 52 times (28 general and 23 regional anaesthetics, data missing in one case) without any MH-related complications. None of the patients had received prophylactic dantrolene. Three MHE patients had received non-trigger anaesthetic agents on three occasions without development of MH. Thirty-five MHN patients had been anaesthetized 64 times, and 13 of these MHN patients had received trigger agents 26 times without any signs of MH. An estimate of the probability of clinical MH developing in MHN patients subsequently anaesthetized with trigger agents was found to be 0-24.7% (95% confidence limits), whereas the probability of clinical MH developing in MHS patients anaesthetized with non-trigger agents was 0-9.7% (95% confidence limits).

Kinetics of the Biosynthesis of Complement Subcomponent C1q by Murine Macrophages: LPS, Immune Complexes, and Zymosan Alone and in Combination With Interferon-γ

We investigated the effects of bacterial lipopolysaccharide (LPS), immune complexes (IC), and C3b opsonized zymosan (AZ) alone and in combination with interferon-gamma (IFN-gamma) priming on macrophage synthesis and secretion of C1q. Our results indicated that LPS, IC, and AZ alone stimulated C1q mRNA and secretion in the absence of IFN-gamma. The increase in mRNA accumulation was detectable after 3 h, peaked at 6 h and was maintained at constitutive levels for 24 h. There was a corresponding early burst of increased secretion of functional C1q after 3 to 6 h which declined rapidly after 9 to 24 h culture of LPS-stimulated macrophages. Priming of macrophages with IFN-gamma and simultaneous triggering with LPS, IC, or AZ produced additive rather than synergistic increases in C1q mRNA accumulation. These same agents inhibited constitutive secretion of C1q in the absence of IFN-gamma priming as determined by autoradiographic analysis of metabolically radiolabeled secretory C1q. Triggering of IFN-gamma primed macrophages with LPS, IC, or AZ also markedly suppressed the increased rate of C1q secretion induced by IFN-gamma in a dose-related fashion. A corresponding dose-dependent increased accumulation of endogenous C1q in cell lysates was detected by Western blot analysis of macrophages which had been stimulated by LPS, IC, or AZ alone or in combination with IFN-gamma. Our findings indicate that LPS as well as FcR and C3bR triggering agents stimulate early and sustained C1q synthesis accompanied by an early and short-lived burst of C1q secretion which rapidly diminished and results in an increased intracellular accumulation of C1q due to ongoing synthesis. IFN-gamma appeared to further amplify the same kinetics of increased C1q mRNA accumulation and decreased extracellular accumulation mediated by LPS, IC, and ZM. Our results suggest that LPS, IC, and AZ alone or in combination with IFN-gamma stimulate early C1q production to modulate macrophage effector functions followed by an inhibition of C1q secretion when the activation process has been culminated.

Triggering Agents Continued After Masseter Spasm

Department of Anesthesiology Med Inn Building C4139 Box 0800 University of Michigan Ann Arbor, MI 48109–0800

The effect of interleukin 3 upon IgE‐dependent and IgE‐independent basophil degranulation and leukotriene generation

Recent investigations have shown that the hematopoietic growth factor interleukin 3 (IL 3) enhances histamine release of mature human basophils. Furthermore, basophils exposed to IL 3 generate large amounts of leukotriene C4 in response to C5a, a basophil agonist which by itself is unable to promote lipid mediator formation. Also IL 3 renders the cells responsive to factors which do not otherwise induce basophil mediator release. Here we show in more detail how IL 3 affects the release of preformed and newly synthesized inflammatory mediators by basophils in response to antigen, anti-IgE, N-formyl-methionyl-leucyl-phenylalanine (FMLP) and C5a. In cells triggered by maximally effective concentrations of these agonists, IL 3 enhances histamine release, although it more profoundly affects leukotriene generation, in particular in response to stimuli which by themselves are inefficient or poor inducers of lipid mediator formation. This change in the mediator-release reaction occurs at low IL 3 concentrations, over the same concentration range of IL 3 of 0.01-1.0 U/ml regardless of which triggering agent is used as a second signal. Pretreatment of basophils with IL 3 results in a left shift of the dose-response curves for mediator release of both IgE-dependent and IgE-independent agonists by approximately one order of magnitude. IL 3 affects only the extent and not the time course of IgE-independent peptide-induced basophil degranulation. By contrast, histamine and leukotrienes are released more rapidly in response to IgE-dependent stimulation after IL 3 priming. IL 3 also shortens the lag time and increases the rate of leukotriene generation in basophils triggered by FMLP. The priming process induced by IL 3 does not require extracellular calcium. Basophils exposed to IL 3 release significant amount of mediators in response to C5a, even in EDTA buffers without addition of Ca2+/Mg2+, indicating that in the presence of IL 3 the Ca2(+)-dependent mediator release induced by C5a becomes partially Ca2+ independent. Thus, we find that IL 3 strongly affects the mediator profile, the amounts of mediators released, the dose-response curves and the kinetic of the release reaction in basophils stimulated with diverse agonists. The data further support the hypothesis that IL 3 plays an important role in inflammatory processes, in particular in hypersensitivity reactions.

Oxy radicals in the eye tissues of rabbits after diquat in vivo.

It is our hypothesis that oxygen free radicals are the triggering agents in cataractogenesis. However, besides H2O2 there is no direct evidence of generation of oxy radicals in the eye tissues. Due to extremely short life of O2-. and OH. it is not possible to measure their cellular steady state levels. We found that indirect spectrophotometric techniques based on superoxide dismutase (SOD)-inhibitable cytochrome c reduction for estimation of O2-., salicylate hydroxylation for OH. and peroxidase catalysed reoxidation of 2,6-dichlorophenolindophenol for H2O2, were suitable, sensitive and reproducible for measurements of the reactive species of O2 produced in the eye tissues by oxy radical enhancer, diquat in the rabbit eye in vivo. After a single intravitreal injection of 60, 120 or 300 nmole diquat in the right eyes, there was a dose-dependent rise in O2. levels, 106-265 fold in the aqueous humor, 34-87 fold in the vitreous humor, 6-19 fold in the lens, and 43-88 fold in the retina as compared to 0.16 microM, 0.21 microM, 2.47 nmole/g and 5.56 nmole/g in tissues of the normal eyes, respectively. There were similar increases of OH. in the eye tissues, and of H2O2 in the aqueous humor and vitreous humor after diquat injection. We propose that endogenous reductants of the eye tissues univalently reduce diquat to its free radical which spontaneously reacts with O2 generating O2. in excessive amounts, further giving rise to H2O2 and OH. triggering cataractogenesis.

Leishmania major amastigotes initiate the L-arginine-dependent killing mechanism in IFN-gamma-stimulated macrophages by induction of tumor necrosis factor-alpha.

Macrophages exposed to IFN-gamma and infected with amastigotes of Leishmania major develop the capacity to eliminate the intracellular pathogen. This antimicrobial activity of activated macrophages correlates with the initiation of nitrogen oxidation of L-arginine, yet other reports suggest that two signals are required for induction of this biochemical pathway for effector activity. In the present studies, macrophages treated with up to 100 U/ml IFN-gamma, or 100 ng LPS, or 10(7) amastigotes produced minimal quantities (less than 9 microM) of NO2- and failed to develop cytotoxic effector activities. In contrast, the combination of IFN-gamma and either LPS (greater than 0.1 ng) or amastigotes (10(6) induced high concentrations (much greater than 30 microM) of NO2- and macrophage cytotoxicity against intra- and extracellular targets. The induction of nitrogen oxidation by amastigotes could be dissociated from LPS-induced events by 1) performing the assays in the presence of polymyxin B (which blocked LPS effects, but not amastigote effects), 2) determining the threshold of IFN-gamma required to prime cells for subsequent trigger (1 U/ml for LPS trigger effects; 10-fold higher for amastigotes), and 3) determining the heat sensitivity of the two trigger agents (amastigote effects abolished at 100 degrees C; LPS effects unaffected at this temperature). Further, culture fluids from amastigote-infected macrophages did not contain detectable LPS (less than 6 pg/ml). Possible parasite and cell-associated factors that could contribute to the induction of nitrogen oxidation and cytotoxic activity of IFN-gamma treated macrophages were examined: only certain intact microorganisms, LPS from a variety of bacteria, and the cytokine TNF alpha were effective. Both NO2- production and intracellular killing were abolished by the addition of anti-TNF-alpha mAb in the assay. TNF-alpha was produced by amastigote-infected macrophages and IFN-gamma dramatically enhanced secretion of this cytokine; IFN-gamma alone had no effect. Endogenous TNF-alpha produced during infection of macrophages with L. major acted in an autocrine fashion to trigger the production of L-arginine-derived toxic nitrogen intermediates that killed the intracellular parasites.

Halothane sensitivity of young pigs in vivo and in vitro

Piglets less than 8 wk of age that are known by genotype to be malignant hyperthermia-susceptible (MHS) do not usually develop characteristic hyperthermia and limb muscle rigidity in response to a brief halothane exposure (5 min of 3%). To determine whether a malignant hyperthermia (MH) episode could nevertheless be provoked by a more rigorous challenge, both genetically MHS (Pietrain) and normal (Yorkshire) 5-wk-old piglets were exposed to a combined halothane-succinylcholine challenge. Only two of eight MHS piglets developed limb rigidity; however, all MHS piglets (and no normal piglets) developed clinical signs of MH episode initiation during the 30-min challenge. Temperatures rose from 37.4 to 38.6 degrees C in MHS piglets while falling slightly in normal piglets. In MHS piglets, venous pH fell from 7.46 +/- 0.02 to 6.88 +/- 0.07, PVCO2 rose from 36 +/- 2 to 126 +/- 17 mmHg, and plasma concentration of K+ rose from 4.0 +/- 0.1 to 7.1 +/- 0.6 mM, whereas all values remained stable in normal piglets. Muscles removed from the same piglets before the halothane-succinylcholine challenge were exposed to halothane in vitro. The muscles from genetically MHS piglets responded to halothane with characteristic depression of tetanic tension and prolonged tetanus relaxation time but did not develop halothane-induced contractures. We conclude that, in the absence of either halothane-induced limb rigidity or in vitro contractures, these young animals were still susceptible to potentially fatal MH episodes on exposure to appropriate triggering agents. The MH defect is apparently partially masked in piglets and expressed fully only in older pigs.

Malignant hyperthermia during isoflurane anaesthesia

Two cases are presented which illustrate the essential features, diagnosis and management of malignant hyperthermia. Both cases occurred in association with isoflurane, and in patients who were exposed during previous anaesthetics to recognised trigger agents without apparent manifestation of the syndrome.

Activation of macrophages to express cytocidal activity correlates with inhibition of their responsiveness to macrophage colony‐stimulating factor (CSF‐1): Involvement of a pertussis toxin‐sensitive reaction

Bone marrow-derived murine macrophages were used to study the relationship between the proliferative response of macrophages to macrophage colony-stimulating factor (CSF-1) and their activation for cytocidal activity against tumour cells. Macrophage activation required two sequential signals. Lymphokines (gamma interferon, interleukin-4) provided the first (priming) signal; bacterial products (lipopolysaccharide, lipophilic muramyl tripeptide, lipopeptide 31362, pertussis toxin) provided the second (triggering) signal. Both priming and triggering agents inhibited [3H]-thymidine uptake by macrophages stimulated with CSF-1. The antiproliferative activity of priming and triggering stimuli was synergistic. Pretreatment with triggering stimuli at 37 degrees C caused a rapid reduction of the subsequent binding of [125I]-CSF-1 to the cell surface at 4 degrees C, whereas priming agents had relatively little effect. Growth inhibition by both priming and triggering agents was largely reversible by washing the cells, and occurred even when they were added as long as 24 h after the growth factor. The ability of pertussis toxin to both inhibit CSF-1-induced proliferation and trigger cytotoxicity in macrophages suggests the involvement of a regulatory GTP-binding protein (G protein) in both processes.

A cytoskeleton-dependent pathway for induction of IL-2 production and a cytoskeleton-independent pathway for IL-2-mediated signal transduction

We have used the synthetic microtubule inhibitor Tubulozole C in order to study the role of the microtubule system in human lymphocyte activation. Microtubule disruption prior to activation with phytohemagglutinin (PHA) resulted in a drastic reduction of IL-2 production. Similarly, using OKT3 or PHA as stimulators, a substantial decrease in proliferation was observed. Although IL-2 receptor analysis performed on the stimulated and antitubular-treated lymphocytes showed a 2-fold decrease in high-affinity and a 100-fold decrease in low-affinity IL-2 receptor expression, a proliferative response to externally added rIL-2 was noticed. This occurred provided the triggering agent was excluded or added in suboptimal concentrations. These results indicate that intact microtubules are necessary for PHA/OKT3-induced proliferation and IL-2 production, but not for IL-2-induced proliferation.

Induction of an endogenous tumor necrosis factor in mice by murine recombinant interferon-gamma combined with a lipid A subunit analog (GLA-60) of low toxicity.

We have investigated the endogenous production of a serum cytotoxic factor when recombinant interferon-gamma (rIFN-gamma) is combined with synthetic lipid A subunit analogs of low toxicity (GLA compounds). The cytotoxic activity of the serum was measured by the crystal violet staining method with L929 cells as a target. Intravenous administration of rIFN-gamma followed by intravenous administration of lipopolysaccharide induced the endogenous production of a cytotoxic factor in the serum. The priming effect of rIFN-gamma appeared immediately and persisted for approximately 20 h after the injection. Administration of lipopolysaccharide as a trigger enhanced the production of the cytotoxic factor in the serum maximally 2 h after the injection. The cytotoxic activity in the serum was completely inhibited by anti-(mouse tumor necrosis factor) (TNF) antibody. A synthetic lipid A subunit analog (GLA-60), which is much less toxic in its endotoxin activities than lipopolysaccharide or synthetic lipid A (compound 506), induced the endogenous production of serum TNF in rIFN-gamma-primed mice. GLA-60 entrapped within liposomes induced the production of serum TNF in rIFN-gamma-primed mice more effectively than GLA-60 solubilized in phosphate-buffered saline. Intravenous or intranasal administrations of rIFN-gamma followed by intranasal administration of GLA-60 produced TNF in the lung washing fluid but not in the serum, indicating that TNF production can be induced locally rather than systemically by the alteration of the administration route of the primer and trigger. These results indicate that GLA-60, a lipid A subunit analog of low toxicity, is a beneficial triggering agent in the production of endogenous TNF, as well as having other immunopharmacological properties, and may provide a basis for cancer (metastases) treatment as a result of its ability to induce endogenous TNF.

Effects of droperidol, haloperidol and ketamine on halothane, succinylcholine and caffeine contractures: implications for malignant hyperthermia.

The effects of two structurally similar butyrophenones (droperidol and haloperidol) and ketamine were evaluated in an in vitro system to determine their potential for eliciting or exacerbating an episode of malignant hyperthermia. Muscle strips from patients referred for diagnostic testing for malignant hyperthermia and muscle strips from the rat diaphragm were exposed to droperidol, haloperidol, or ketamine prior to challenge with halothane, succinylcholine or caffeine. If any agent augmented the contracture response to the malignant hyperthermia triggering or diagnostic agents, then the agent was considered unsafe for use in malignant hyperthermia susceptible patients. Droperidol 10 mumol/l and ketamine 100 mumol/l did not induce contractures in human or rat skeletal muscle when added alone, nor did they augment halothane, succinylcholine or caffeine contractures. These agents appear to be safe for use in patients susceptible to malignant hyperthermia. In contrast, haloperidol 10 mumol/l augmented the response to succinylcholine about 1.5-fold and may be contraindicated in MH susceptibles.

Changes in the expression of macrophage antigens associated with activation for tumor cell killing

Cultured murine bone marrow macrophages (BMM phi) can be induced to kill tumor cells in vitro by combined treatment with a priming (IFN-gamma) and a triggering (LPS) agent. We have examined the expression of cellular antigens accompanying this activation by Western blot analysis with rabbit antisera raised against unstimulated and fully activated BMM phi and assayed the effect of these antisera on macrophage-mediated tumor cytotoxicity. Killing of Yac-1 target cells was slightly enhanced by antiserum against unstimulated BMM phi but inhibited 54% by antiserum against activated BMM phi. The following changes in antigen expression are shown to be associated with discrete stages of activation and localized to the cytosolic or membrane fractions. Antigens with apparent molecular weights of 109, 67, and 48 kd are expressed after priming with IFN-gamma whereas LPS induces the enhanced expression of antigens with molecular weights of 46, 30, and 14.4 kd. One antigen with a molecular weight of 54 kd apparently is only expressed by fully activated BMM phi treated with a combination of IFN-gamma and LPS. Antigens with molecular weights of 170 and 21 kd are repressed by LPS and IFN-gamma respectively. IFN-gamma partially counteracts changes induced by treatment with LPS alone when used in combination with LPS. All antigens are localized in the cytosolic fraction except the 54 kd and to some extent the 30 kd, which were detected in the membrane fraction. The 21 kd was only detectable in crude lysates and thus presumably is of nuclear origin.(ABSTRACT TRUNCATED AT 250 WORDS)